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Specialty Medication Prior Authorizations

Beginning January 1, 2023, National CooperativeRx will take over specialty medication prior authorizations for our member groups’ plan participants. Similar to our innovative clinical programs, this service is provided at no cost to our members.

Controlling Specialty Costs

We have identified an opportunity to save members millions of dollars in specialty medication costs – by managing specialty medication prior authorization functions within our Cooperative.

We conservatively estimate $3.5 to $5 million in savings across our Cooperative in specialty medication prior authorization functions alone. In addition to saving our members money, improving the participant experience is another major goal of our in-house Specialty Medication Prior Authorization program. This shift in responsibility will lead to a more high-touch clinical review of our participants’ specialty medications.

In 2021, specialty medications among National CooperativeRx membership accounted for 1.5% of claims, yet 48.5% of total pharmacy spend.

Specialty medications are prescriptions used to treat specific chronic and/or genetic conditions. Specialty medications are costly to pharmacy benefit plans due to the special handling required.

Prior authorizations entail the reviewing of medications or procedures to ensure clinical appropriateness. Prior authorizations may be required by pharmacy benefit plans before providing coverage.

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